Surgeons can insist they're sticking to the surgical checklist, but a camera in the operating room might tell another story.

North Shore-Long Island Jewish Health System in New York is looking to take checklist adherence — and a host of other patient safety tactics — to the next level by using remote-video auditing to keep clinicians and staff honest.

"The operating room involves nurses, doctors, patients, a cleaning crew, people bringing out sterile equipment. It's a tremendous dance, the most complex environment in any hospital," says John Di Capua, M.D., vice president of anesthesiology services for the 16-hospital system. "So it's many orders of magnitude or more difficult to monitor and to improve any activity."

North Shore-LIJ first tested such monitoring technology in its intensive care units several years ago to keep an eye on hand washing. That proved successful, Di Capua, says, so leaders decided to test the approach in the OR to increase safety and efficiency.

They started in March at Forest Hills (N.Y.) Hospital, which has eight ORs. Cameras, monitored off-site by a third party, keep vigil over the entire process, from pre- to postsurgery, making sure the doctor follows each step in the checklist. Images from the equipment are clear enough to show what's happening, but fuzzy enough to distort the patient's features, says Rita Mercieca, R.N., executive director of the hospital.

The technology is used to improve throughput by alerting cleaning crews that an operating room is ready to be set up for the next case. As a result, the hospital has improved its turnover metrics by 15 percent. And the technology confirms that the room has been cleaned properly to reduce risk of infection.

"Time-outs are being done 100 percent of the time, they're being done at the correct duration, and everyone is engaged in the process. That's a remarkable achievement," Mercieca says.

Now, the health system is expanding the approach into 24 ORs at Long Island Jewish Medical Center, and is eyeing the entire network. Eventually, it may be the standard throughout the industry, says Di Capua, who is also chief medical officer of North Shore-LIJ's anesthesiology provider, North American Partners, a partner in the pilot.

"We've tried a lot of different things throughout the country to get people to not rush, to not be distracted," he says. "Using video and telling people exactly, 'Look, we see that you're distracted' is powerful information for them to say, 'Wow, I guess I really can do better.' "